69 - Posterior Calcaneal Heel Flashcards
Etiologies of posterior heel pain
- Retrocalcaneal bursitis
- Prominent superior calcaneal tuberosity- bursal process (Haglunds deformity or “Pump bump”)
- Insertional Achilles Tendinosis (IAT)
- Insertional Achilles Calcific Tendinosis (IACT)
- Posterior calcaneal exostosis
- Equinus
Clinical assessment of posterior heel pain
- Thorough medical history
- HPI
- M/S; Biomechanical exam
o Equinus
o Cavovarus
o Over-pronation/pes plano valgus
o Radiographs?
o Specific location of pain - NOTE: Don’t just treat x-ray, treat patient based on exam and history
Retrocalcaneal bursitis
- Inflammation of the bursa between Achilles and calcaneus
- Hallmark pain- anterior to Achilles and superior to the calcaneal tuberosity
- Common in runners/athletes – overuse injury or INCLINE running
- NOTES: If patient has an inflammation of the bursa – you can imagine that if you are running uphill, it is pinching the normal anatomic bursa, causing pain and additional edema
- Can cause increase in inflammation of the tendo calcaneus
- When you squeeze side to side just anterior to the Achilles on the posterior calcaneus, a patient with retrocalcaneal bursitis will experience high levels of pain – HALLMARK SIGN***
Signs and symptoms of retrocalcaneal bursitis
- Pain with compression ANTERIOR to Achilles tendon just proximal to insertion – this is called the “two finger squeeze test”
- Edema and/or Erythema in the bursal region
- Pain with activity
- Burning
Notes on signs and symptoms of retrocalcaneal bursitis
NOTES: There will be some times of diffuse edema and swelling to the area, so you NEED to look at both sides of the extremity
o It may be relatively normal until you compare it to the other side
o Often times patients will describe a burning sensation to the area
o Increased pain with activity (going up steps really bothers it)
Treatment of retrocalcaneal bursitis
- Rest, Ice, activity modification
- Heel lift/orthotics
- NSAID’s
- Offloading with cam boot
- Injections – Use caution-Make sure ONLY inject into the bursal sac and warn patient of risks – Possibly need to protect after with decreased activity or non-WB
- PT
- Surgery
Surgery options for retrocalcaneal bursitis
o Open resection of bursa
o Endoscopic
o Calcaneal osteotomy/exostectomy
Notes on treatment options for retrocalcaneal bursitis
o Heel lift – Raises heel out of shoe to prevent rubbing and releases some tension on the Achilles
o Downhill creates the posterior process is pushed forward to decrease shearing forces
o Injection is not my first go-to, usually do very conservative first, but does do it
o Do NOT inject into tendon, but because the bursal process does get inflamed, when you go in there surgically there is a lot of red, blood, inflammation, etc.
o Have them stop running for a period of time
o Can either just go in and take out the bursa or go in and take out the exostosis
o If you go in laterally you can go in without damage
Haglund’s “pump bump” deformity etiology
o Anatomic variant o Biomechancial (i.e. varus)
Description of Haglund’s “pump bump” deformity
o May involve the entire posterior aspect
o Different than IACT
o No osteophytes (could be present concomitantly with different etiology/pathology)
o May present with retrocalcaneal bursitis
True Haglund’s deformity
NOTE: Students tend to want to call anything on the back of the calcaneus as a Haglund’s deformity, but it’s not
o A true Haglund’s when we are talking x-ray and we see a bony prominence on the superior aspect of the posterior calcaneus – Needs to meet x-ray measurements
o Sometimes the term is used loosely as any bump on the back to the heel – this is actually a “pump bump” but it doesn’t have another name, so people will call this a Haglund’s deformity too
Signs and symptoms
- Usually irritation from shoe gear
- Skin irritation/breakdown – possibly from high heel shoes
- Women ~16-35 (can be present at any time, male or female)
- NOTES: Shoe gear irritation is huge – high heel shoes will rub on this area
- Hyperkeratosis is common, especially in older women – the hyperkeratosis is irritating
Physical examination
- “Pump bump”
- May have erythema and/or edema but not very common
- Pain from shearing
- May have pain on palpation (sometimes only painful with/after shoe wear)
- Hyperkeratosis
Example of IACT
This is NOT Haglund’s primarily: IACT with concomitant Haglund’s
- There is a calcification of the tendon
- The pain is not primarily from the Haglund’s deformity
- IACT = Insertional Achilles Calcific Tendinosis
Haglund’s deformity radiographic evaluation
Lateral, oblique, axial
o Measurements may not be of any significant benefit
Prominent posterior superior aspect-Bursal Process
o Fowler And Philip Angle 75° (65°)
o Total Angle 90° - Ruch
o Parallel Pitch Lines - Pavlov
Angles measured on radiographs
- 1 = Fowler and Philip (>75) - Calcaneal inclination to posterior calcaneus
- 2 = Calcaneal inclination
- 3 = Total angle (>90)
Parallel pitch lines
- Fowler Philip = calcaneal inclination to posterior calcaneus
- Then draw line parallel to that at posterior facet
- Connect those two lines with a line that extends
from the posterior facet - A normal calcaneus should NOT have any bony
prominence extending above this line
Haglund’s deformity treatment
- Heel Lift
- Open Shoe
- Orthotics
- Padding/silicone sleeve – good in elderly patients
- Ice
- NSAID’S (pain relief only)
- Physical Therapy
- Injections?
- Surgery
Surgery for Haglund’s
- Bump resection/exostectomy (remove the bump)
- Calcaneal osteotomy (Keck and Kelly)
- Keck and Kelley = dorsal closing wedge
Keck and Kelley
o Addresses Hagland’s deformity by moving the posterior portion of calcaneus forward
o If you take a wedge out, as you close, it will move it forward and make it straighter
Bone removal for Keck and Kelley
- The anterior osteotomy is drawn at 90°
to the weight-bearing surface starting at
the plantar apex - This osteotomy design consistently provides
adequate correction to effectively
decompress the stress on the Achilles in the
retrocalcaneal bursal region and reduces the
bump to alleviate shoe pressure
Insertional Achilles Tendinosis/Tendinopahty
- Chronic degeneration of the Achilles Tendon with thickening/hypertrophy at the insertion or just proximal to it
- May present prior to calcification
- TENDINOSIS = with the Achilles tendon, when there is pain, except for acute onset of pain, there are not inflammatory markers present
- Inflammatory markers would be in the paratenon, but not in the tendon itself
- If this is continued, we see degenerative changes of the Achilles tendon, NOT INFLAMMATION OF THE TENDON
- This is important because the most common treatment is NSAIDs (anti-inflammatory drugs)
- Important to know this for treatment
- This will usually be present prior to Achilles tendon rupture
- This is another time when you want to examine bilaterally because there could be slight changes
- They can have swelling, redness, etc
Signs and symptoms of insertional Achilles tendinosis/tendinopathy
- Thickening of the tendon/widening of the calcaneus
- Edema and or erythema
- Pain greatest first thing in morning/after sitting
- Pain with increased activity/running
Conservative treatment for insertional Achilles tendinosis/tendinopathy
- Heel lift/orthotic
- Shoe modification
- RICE
- PT
- Kinesio tape?
- NSAID’s for pain only
- Cam boot if recalcitrant
PT options
o Alfredson Protocol of eccentric training
o Doesn’t work as well as intrasubstance
o Manual stimulation (ASTYM)
o Gait analysis
Surgical treatment of insertional Achilles tendinosis/tendinopathy
- Gastroc recession
- Debridement/debulking
- Stimulation with scalpel
- Radiofrequency/shockwave (ECSW)?
- Ultrasonic cutting (Tenex)
Retrocalcaneal exostosis
- Exostosis with or without “spurring” at Achilles Tendon insertion
- May see calcification of tendon, bursitis, tendonosis or Haglund’s deformity
Retrocalcaneal exostosis signs and symptoms
- Dull aching pain, tenderness at insertion
- Sharp/burning
- Achilles Tendon thickening
- Pain with ROM and palpation
- Equinus
Conservative treatment for retrocalcaneal exostosis
- Conservative treatment: Similar to Haglund’s deformity
- Offload in cast or cam boot if potential fracture
Surgical treatment for retrocalcaneal exostosis - Incision
o Multiple variations: Medial, Lateral, MIDLINE***, Curve, L
o Careful soft tissue handling
o Straight down, do not open layer by layer
Surgical treatment for retrocalcaneal exostosis
- Split Achilles Tendon longitudinally or remove it from calcaneus (transverse)
- Resection of exostosis using saw, osteotomy and mallet
- Remove bursa?
- Debride thickened tendon?
- Address other pathology (i.e. Equinus)
- Reattach Tendon – use anchors (one or two absorbable or non-absorbable suture-like material)
Chasing the bump
- Compromise Achilles Tendon Insertion (leads to weakening of the Achilles tendon)
- Resection of too much bone
Complications of surgical treatment of retrocalcaneal exostosis
- Wound dehiscence
- Achilles Tendon rupture
- Painful/ hypertrophic scar
- Nerve entrapment
- Equinus
- Fracture
- Recurrence
